Dentistry

Gold standard for

chairside restorations
Highly esthetic and high-strength monolithic IPS ­e.­max CAD restorations
A report by Dr Andreas Kurbad, Viersen/Germany

IPS ­e.­max CAD has had a lasting impact on the ­dental

market over the last decade. The clinical reliability
of hardly any other dental material has been so well
­documented. Highly esthetic and high-strength mono­
lithic IPS ­e.­max CAD restorations have become an
alternative to metal ceramics and offer a comparable
survival rate.

Introduction
As dental CAD/CAM systems have become established in
dentistry, the vision of producing indirect restorations in the
dental practice has become reality. An intraoral 3D camera for
digital impression-taking, an intuitive design software and a
numerically controlled milling machine are the technologies
that enable restorations to be created onsite in a short time
compared to manufacturing in the dental lab. In addition to
the time advantage, the digital method has also the benefit
of saving resources, such as impression materials. Furthermore,
the need for temporary restorations is eliminated.
Note: Adhesive bonding achieves
the best values if it is performed
­immediately after tooth preparation.
Requirements placed on materials for
­chairside manufacturing
The technical prerequisites go hand in glove with materials
that are suited for chairside manufacturing. Such materials
should be strong enough to withstand a lifetime of use.
However, very strong materials are difficult to process in a
milling unit, especially since onsite manufacturing processes
are expected to take only a short time. Furthermore, the
material should also exhibit a tooth-like appearance in ac-
cordance with a certain esthetic sensibility. Onsite fabrication
methods are not conceived for elaborate enhancements,
such as ceramic veneers. The term “monolithic restoration”
has become established in this context. This term describes a
material that meets the requirement for adequate esthetic in-
tegration straight away, without necessitating any reworking.
Furthermore, the materials should offer good conditions for
adhesive bonding, especially as ever more tooth-preserving
preparation techniques are preferred (Table 1).
Basic requirements for chairside materials
Good resistance to oral conditions
High strength
Easy and fast machining in the milling unit
Tooth-like esthetic characteristics
Table 1
Historical review
The beginnings of CAD/CAM fabricated chairside restorations
can be traced back to a certain feldspar glass-ceramic. The
first attempts of the CEREC era began with the Vita Mark I
blocks. The material was further developed and for a long
time, Vita Mark II was considered the sole standard for pro-
cessing restorations onsite. The material was relatively easy
to grind and polish and was capable of fulfilling the esthetic
requirements well. With a flexural strength of 120 MPa, its
field of application was, however, limited. Adhesive cemen-
tation was indispensable to ensure a durable stability. By
today’s standard, relatively high minimum thicknesses were
required, resulting in a correspondingly high removal of
tooth structure and, at times, unfavourable geometries in
the design of the cavities. The introduction of the ProCAD
blocks (1998) did not bring the decisive breakthrough either.

12 Dentistry reflect

This material was based on leucite-reinforced glass-ceramic
and featured a flexural strength of 140 MPa. The blocks are
still available in an optimized version as IPS Empress® CAD or
as IPS Empress CAD Multi blocks (185 MPa) to this very day.
Although these materials produced good to very good long-
term clinical results, they always entailed a risk for failure in
the form of fractures.
Introduction of IPS ­e.­max CAD
A new category of glass-ceramic materials brought about
the decisive improvement in 2005: lithium disilicate. This
material was instrumental in establishing CAD/CAM sys-
tems for chairside applications. Ivoclar Vivadent launched
the IPS ­e.­max® CAD material on the market. Initially, it was
02 — Veneered and non-veneered MO restorations were eval-
uated and compared with each other in this case. Although
IPS ­e.­max CAD MO is typically a framework material, the
differences between the two restorations are not at all that
noticeable.
Issue 01 / 2018 Dentistry
01 — IPS ­e.­max CAD
has had a lasting
impact on the dental
market over the last
decade.
available in MO blocks (Medium Opacity) with a relatively
high opacity. These blocks were designed for the veneering
technique (Fig. 1). This meant that this material was, in the
main, inappropriate for chairside applications. However, this
is not where the story ends: Initial experiences showed that
the material was dotted with excellent optical properties. In
addition, the manufacturing technology made the material
attractive for use in the dental practice even if it required a
crystallization process of approx. 30 minutes. Above all, it was
the flexural strength of 360 MPa, which was clearly superior
to all materials used in this segment so far. Soon we began
to use the IPS ­e.­max CAD MO blocks for creating monolithic
restorations, especially for crowns, even if originally this was
not the intended use of the material (Figs 2 to 3).
03 — Monolithic MO crown in situ
13
IPS ­e.­max CAD and its levels of translucency
Driven by the excellent optical properties, users urged the
manufacturer to increase the translucency of the blocks and
to enable the fabrication of monolithic restorations. Ivoclar
Vivadent responded by introducing IPS ­e.­max CAD LT in
2007 (Figs 4 to 11). LT stands for Low Translucency. These
04
blocks ensured results that met a high esthetic standard,
particularly when used in conjunction with the accompanying
IPS ­e.­max CAD Crystall./Shades and Stains characterization
materials. With its user-friendly and compact design, the
Programat CS (2007) furnace facilitated the applications at
chairside. On the one hand, the LT blocks were sufficiently
translucent to mimic the characteristics of the natural tooth
05
structure and, on the other, they were sufficiently opaque
to mask “problematic” substrate. Even today, this material
may still be called a universal ceramic. Nonetheless, it may
be regarded as a step forward that another level of translu-
cency was launched in 2009: These were the HT blocks (High
Translucency) (Figs 12 to 15). If used in combination with an
appropriate luting material, this blocks allowed the shade of
06
the substrate to be integrated into the overall optical effect
04 — Defective restorations in the upper pos-
of the restoration. This meant that partial crowns and veneers
terior region in urgent need of repair
could now be created with ease directly onsite in a single
visit. The trend towards ever less invasive procedures led to
05 — Preparation with the gums in critical
the introduction of still another variant of IPS ­e.­max CAD: the
conditions
Impulse materials (2011). Impulse Opal O1 and O2 are ideal for
fabricating monolithic restorations with the aim to reproduce 06 — The CEREC software V3.8 did not yet
dental enamel. Outstanding results can be achieved with allow entire quadrants to be reconstructed in
comparatively minimal effort. As many users had ­difficulty a single step.

in classifying the Impulse blocks appropriately in the product

portfolio, some parts of the assortment were taken over into
the recently created category MT (­Medium Translucency,
2015). The IPS ­e.­max CAD materials of the medium translu-
cency category are mainly used to improve brightness values.
Altogether, five different levels of translucency are available
today. With this “toolkit”, monolithic restorations offering
an utmost level of esthetics can be accomplished in a variety
of clinical situations. The Shade Navigation App assists in
07 selecting the correct translucency. In a few easy steps, this
app provides useful recommendations on the selection of
the correct blocks.

Range of indications
for chairside applications
The range of indications for IPS ­e.­max CAD evolved in tandem
with the provision of the blocks. The LT variant is the first
choice for crowns and indications that involve “problematic”
substrates. Larger blocks enable the onsite fabrication of bridg-
08 es (up to the second premolar as the terminal abutment). In
this case, the processing time is longer than for single-tooth
07 — Crowns directly after having been ground from
restorations. With the HT variant, inlays, onlays and partial
IPS ­e.­max CAD LT
crowns can be manufactured to a high esthetic standard.
08 — Monolithic crowns after having been finalized, crystal- At IDS 2017, Ivoclar Vivadent launched the IPS ­e.­max CAD
lized and characterized. 530 MPa initiative. Eleven years of continued quality testing

14 Dentistry reflect
09 10

09 — Because of the critical conditions of the

gums, the crowns (2007) are seated using a
conventional cementation method with glass
ionomer cement (Vivaglass CEM).

10 — Check-up of the crowns in 2012

11 — Situation after ten years (2017): The

crowns are intact and do not show any vis-
ible signs of damage. Abrasion facets can be
observed, e.g. on the bucco-distal cusps of the
11 upper left 6.

have shown that IPS ­e.­max CAD provides actually a mean bi-
axial flexural strength of 530 MPa. This is also reflected in the
consistently positive results of many scientific studies on the
survival rate of IPS ­e.­max CAD restorations (literature). In view
of the consistent further development and favourable long-
term clinical results, the minimum thicknesses recommended
for adhesively cemented IPS ­e.­max CAD crowns have been
reduced to thinner dimensions. This means that preparing the
teeth is easier and more tooth structure can be preserved. It
also allowed the range of indications to be extended to in-
clude occlusal veneers, which have come to play a key part in
raising the bite in the posterior region. Since the introduction

12

14 13

12 — Two insufficient amalgam fillings needing to be replaced

13 — The cavities were restored with IPS e.max CAD HT restorations produced
at chairside.

14 — The final result in 2008: beautiful optical integration

15 — Check-up after 5 years (2013): restorations still look beautiful

15

Issue 01 / 2018 Dentistry 15

of the optically brilliant Impulse blocks (Figs 16 to 21) and the
MT materials (Figs 22 to 26), IPS ­e.­max CAD has barely been
rivalled for strength and esthetics in the fabrication of veneers
and partial anterior crowns.
In 2013, abutment blocks made of IPS ­e.­max CAD were
launched. These blocks are cemented to an adhesive base
(Ti base) (see Figs 31 and 32). Thus, it has become possible to
create single-component monolithic restorations, which are
referred to as hybrid abutment crowns. The chairside pro-
duction of such crowns is realistic and has established itself
as a standard among CAD/CAM users for fabricating implant-­
supported single-tooth restorations in the posterior region.
19 — … and provide a high brightness effect in direct light due
to the high level of opalescence and fluorescence.
20 — The teeth were restored to the correct proportions and the
smile line was optimized. The patient was satisfied with the
result.
21 — The 3-year check-up did not show signs of ageing.
16 Dentistry
16
17
18
16 — The UR1 and UL1 of this 23-year-old
female were damaged in an accident and
restored with composite material.
17 — As the result was esthetically unsatisfac-
tory, the teeth were prepared using a planned,
minimally invasive procedure.
18 — The exceptional optical properties
of IPS e.max CAD Impulse O1 enable a
­completely natural appearance …
Typical workflow
Preparation is mostly minimally invasive due to the high
strength of the material. There are no differences with other
types of restorations when it comes to optical impression-­
taking and computer-assisted design. The differences only
become noticeable during processing in the milling and
grinding machine. Lithium disilicate is a material that cannot
withstand unlimited forces. Gentle processing is essential. The
grinding process for a typical posterior crown takes on average
15 minutes if an MC XL milling unit is used (­Dentsply Sirona).
The precision can be increased by using the extra fine pro-
cessing option. The processing time doubles with this option.
The future lies in the use of new technologies. The P
­ rograMill One
milling and grinding machine will deliver significantly better
results in less time as it incorporates innovative new t­ echnology.
For instance, the 5-axis turn-milling technology (5 XT) uses a
robotic arm, rather than a milling motor, to move the work-
piece. This enables a consistent milling and grinding procedure
with many degrees of freedom and increased levels of accuracy.
Only a minimal amount of reworking is required after the
machining process. As the material is considerably easier to
reflect
 22 — A patient wearing
10-year-old veneered zirco-
nia crowns wants her esthetic
appearance to be improved.
The crowns appear rather
dark and grey. The propor-
tions look unflattering.
22 23
23 — The variation in the
shade of the preparations
made it necessary to use a
relatively opaque material
that nonetheless provided a
certain brightening effect.

24 25 24 — The new restora-

tions were ground from
IPS ­e.­max CAD MT.

25 — The preparations were

effectively concealed under
the new crowns (cut-back
method) and the brightness
of the teeth was considerably
increased.

26 — The final result shows a

26 pleasing esthetic a
­ ppearance.

process when it is in its pre-crystallized blue state, corrections should be implemented directly
at the grinding stage. A try-in can be performed before the crystallization process is carried
out if the restoration is machined onsite (Figs 27 to 29).

Crystallization is a mandatory step in the IPS ­e.­max CAD workflow. The restoration is secured
on a special firing tray with the help of support pins and firing auxiliary paste (IPS Object Fix).
Polishing is basically possible. However, it is also possible to apply a spray glaze or glazing paste.
Individualized shade characterizations can be created with IPS ­e.­max CAD Crystall./­Shade/­Stains
materials at the same time as the glaze is applied. The crystallization process takes 15 minutes in
the best case when using the spray glaze (speed crystallization), otherwise it takes 25 ­minutes.
Developed specifically for the chairside method, the Programat CS furnaces (e.g. the new
­Programat CS4 universal furnace) provide optimum results in the shortest possible time and
are therefore a sensible recommendation (Figs 30 to 34).

27 28

27 — Preparation for a three-unit bridge with an ovate pontic

design

28 — Try-in of the ground monolithic bridge whilst still in the

pre-crystallized state

29 — IPS e.max CAD allows the fabrication of restorations for

29 esthetically sensitive areas without the need for veneering them.

Issue 01 / 2018 Dentistry 17

30 — The lower right 6 had been endodonti-
cally treated but could not be saved because of
recurring inflammatory processes.

31 — After the extraction and implantation

procedure, the site was ready for the new
restoration.

32 — A monolithic hybrid abutment crown

was created on the basis of a Ti base connector
using CEREC software. Crystallization and
staining were again carried out in a single 30
step.

33 — Beautiful result in 2012

34 — Check-up after five years: the result is

proof of the success of this therapy concept.

31

32 33

34

Thanks to the high strength of the materi-
al, several options are available for seating
the restorations. Adhesive bonding should
always be the preferred method. Conven-
tional cementation is also possible but re-
quires a retentive preparation pattern, which
is considered outmoded by today’s standard.
­ onobond® Etch&Prime (etching and silanating in a single step) can be used
M
for conditioning the ceramic. Which kind of cementation is used depends
on the clinical situation. Posterior crowns can be seated quickly and easily
using the self-adhesive SpeedCEM® Plus. For higher esthetic requirements,
Variolink Esthetic should be employed. This material is available in a dual-­
curing and purely light-curing version. More information and guidance is
provided by the Cementation Navigation System (CNS).

18 Dentistry reflect
35 — The tooth had already been endodontically treated and 36 — Extraction and immediate implantation was followed
restored with a PFM crown. After a root fracture, it could no by a temporization phase, at the end of which a pleasing emer-
longer be preserved. gence profile had developed.

37 38
37 — The abutment was ground from an
IPS e.max CAD Abutment MO block and the
crown from IPS e.max CAD LT.

38 — The completed restoration in 2012:

a pleasing result.

39 — Check-up after 5 years is proof to the

long-term stability of this treatment concept.

39

Conclusion
IPS ­e.­max CAD is the gold standard for chair-
side restorations (Figs 35 to 39). ­Together
with the Programat furnaces designed
for IPS ­e.­max CAD and the corresponding
­cementation materials, a coherent system
that ensures the necessary robustness in a wide range of applications has
been developed. IPS ­e.­max CAD sets benchmarks for efficient, tooth-pre-
serving all-ceramic restorations that offer a high level of clinical reli­
ability. The new zirconium oxide blocks (IPS ­e.­max ZirCAD LT) complete
the over­arching IPS ­e.­max system, in line with the motto IPS e.max – all
ceramic, all you need.
Literature is available on request from the editors

Dr Andreas Kurbad
Dental practice/EC Excellent Ceramics UG
Viersener Strasse 15
41751 Viersen Cementation
Germany Navigation
www.kurbad.de System

Issue 01 / 2018 Dentistry 19